Basic Information
Provider Information | |||||||||
NPI: | 1568568376 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WELLS | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD LCP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 91734 | ||||||||
Address2: |   | ||||||||
City: | RICHMOND | ||||||||
State: | VA | ||||||||
PostalCode: | 232911734 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8043586100 | ||||||||
FaxNumber: | 8043427619 | ||||||||
Practice Location | |||||||||
Address1: | 11958 W BROAD ST | ||||||||
Address2: |   | ||||||||
City: | HENRICO | ||||||||
State: | VA | ||||||||
PostalCode: | 23233 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8043604669 | ||||||||
FaxNumber: | 8043646521 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/16/2006 | ||||||||
LastUpdateDate: | 05/25/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 0810001817 | VA | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
ID | Type | State | Issuer | Description | 198317000 | 01 | VA | MAGELLAN | OTHER | 31705 | 01 | VA | VALUE OPTIONS | OTHER | 356101 | 01 | VA | PHCS | OTHER | 4529892 | 01 | VA | AETNA | OTHER | 190033 | 01 | VA | COMPSYCH | OTHER | 082546 | 01 | VA | SENTARA BEHAVIORAL | OTHER | 191723 | 01 | VA | HEALTHKEEPERS | OTHER | 341259 | 01 | VA | UBH | OTHER | 381756 | 01 | VA | ANTHEM | OTHER | 611681 | 01 | VA | OPTIMUM CHOICE | OTHER |